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Rev. 51197 m c O O U C 7 0 U O d E M X d �o U z d Z E W p c W U � W LL CL O n c N i Z LL ri (7 STATE OF NEBRASKA- DEPARTMENT OF HEALTH AND HUMAN SERVICES FINANCE AND SUPPIT0000-0340 VITAL STATISTICS CERTIFICATE OF DEATH FIRST MIDDLE LAST 2 SEA 3. DATE OF DEATH /MdrA Dler yWd Helen F. Campbell Female July 149 1999 IT Y AND BTATF OF BIRTH /Il nd ar U S A. name Camrryl Sa AGE - Last SIAMOy UNDER 1 YEAR UNDER 1 DAV 6. DATE OF BIRTH /Abram Oft YW (Yrs1 Sb. MOS I DAYS 5c. HOURS- MIN$ Februar 16, 1910 Hawarden Iowa 89 7. SOCIAL SECURTIY NUMBER 6a. PLACE OF DEATH 506 -09 -7280 HroSPITAL ❑ InpOAOd OTHER ❑ NunigHbM iIb FACILITY -Nam• !N nm mxmuadl. piva seats And number) -. __ ER OuIpe1NM ❑ ResdaneO St. Francis Medical Center ❑ DOA ❑ Om"/$p1e'"r M COUNTY OF DEATH CITY TOWN OR LOCATION OF DEATH /•d• gNkadl 6d INSIDE CITY ll I CaMge nit a 5•I 12th Grade Grand Island MAIDEN SURNAME ❑ Opdall Hall RF310FNCE •STATE 9s COUNTY 9c. CITY. TOWN OR LOCATION 6d. STREET AND NUMBER Ikwkvvv 70 com N IN O r y 1.1-01 Nebraska Hall Grand Island 247 S. Locust 68801 Y« I No ❑ RACE - Is g. White Black Amerman Mien. 11. ANCESTRY 10q Italian, Me.ican. German, Oct 12. MARRIED ❑ WIDOWED 17 NAME OF SPOUSE N n?17 /r`'•rrreUMrr Hemel skl lSnardyl (Soealy) Am i NEVER M DIVORCED Robert L. Campbell White er can MARRIED USUAL OCCUPATION IGne kMd d —k done dlydop rimer 11b KIND OF BUSINESS INDUSTRY Of aorkap Lb. even N reered) Telephone Operator Bell Telephone FATHER - NAME FIRST MIDDLE LA51 17. MOTHER FI George NMN Fox Edith WAS DECEASED EVER IN U.S. ARMED FORCES? t9a. INFORMANT - NAME (Yes . no a unk.) I IN yes "It war Ord dales d serviCeel No ---- - - - - -- Robert L. Camplb 7 INFORMANT MAILING ADDRESS (STREET OR R F . NO.. CITY OR TOWN. STATE. DPI 247 S. Locust, Grand Island, Nebraska 68801 MBAIMER - SIGNATURE 6 LICENSE�� NO 2t —METHOD OF DISPOSITION 21b. DATE K. (.ca.•1.(��- �� 43 ❑X owlet ❑ Removal July 17 19991 Weatlawn Memorial Park 229 FUNERAL HOME -NAME 2 1d. CEMETERY OR CREMATORY LOCATION CITY OR TOWN STATE Livingston - Sondermann F.H. ❑l, 'XO" ❑0- 1"1- Grand Island, Nebraska 22b FUNERAL HOME ADDRESS (STREET OR R.F.D. NO CITY OR TOWN. STATE, 21P) 601 N. Webb Road, Grand Island, Nebraska 68803 -4050 23 IMMEDIATE CAUSE (ENTER ONLY ONE CAUSE PER LINE FOR (0, lb). AND (C)) ' MMrvO belarOMT ornsl are neaa• 1 R X", lei C dio Mona CE DUE TO. OR AS A CONSEOU OF 1 aAlsmal bef~ dnW arvl ram' 1b) ' — DUE TO. OR AS A CONSEOUENCE OF I MNarvO be~ Ow OM deem I I UCAT10N ISpacAy •tiY 1.611••1 /•d• gNkadl .Henley or 9OeorMery b -121 CaMge nit a 5•I 12th Grade MIDDLE MAIDEN SURNAME NMN Opdall OTHER SIGNIFICANT CONDITIONS - CordiOons momdbuang to Aa death but not related PART a1 IF FEMALE. WAS THERE A 21 AUTOPSY 23 WAS CASE REFERRED TO MEDICAL PART PREGNANCY IN THE PAST 3 MONTHS? �- EXAMINER OR CORONFPy A (Agee 10 -511 Vq No Vet El No Ys No Tait 26b DATE OF INJURY /MO. DAY, Yr.1 I 26c. HOUR OF NJURY I 26d. DESCF48E NOW NJURY OCCURRED E] Acr-klenl E] Undetermined M El SUirde El Pendinq 262. INJURY AT WORK I 281 PLACE OF.INJ� Y - At hop. form. 2000. ISCbry Hbmicde Inveogstn ;, Yes ❑ No ❑ 06 aabm8 /�at�l'/ 278 DATE OF DEATH /Ab. Dey ✓r.l 6 a r 27b DATE SIGNED /Ab Day. Yrl 27c. TIME OF DEATH � ZS a M s 27tl to sIe best d my knoyMdge deaA otttnrad M N1a 6ma, tlets end 011e0 arld duo b NN r°- ealrselelstaled. B ❑ YES ❑ NO W UNKNOWN FOR VITAL STATISTICS USE ONLY LOCATION ❑ YES 1.0 NO "0. delle and AI R.F.D. NO. City UN'Ua ` or— Zee TEAS OF DEATH 19 13r 3'VA q W. YrI Zed PRONOUME00EAD p*yal p N IIIY e�OKV e —a — I etlllwd � �e.it� ��11 i 11l l i I i q JI WWOUNOT GRANTED? 1 ❑ YES ND -and Island. NE 68801 hereby certify this to be a true and correct copy of the original filed with the State of Nebraska by Signed in esence thi d. ?y of NOiar Publlc. LGENERAL NOTARY -State of Nebraska -- Y TERRY L. LOSCHEN My Comm. Exp.